(a) In addition to Section 80070, the following shall apply.
(b) The following information regarding the child shall be obtained and maintained in the child's record:
(1) Legal name, preferred name if different from legal name, and preferred gender pronouns.
(2) Political affiliation with an Indian tribe or Alaskan village, including membership or citizenship, if applicable.
(3) The name, address, and telephone number of all adults with whom the child was living immediately prior to the current placement.
(4) The name, address, and telephone number of the child's parent(s), if known.
(5) The name, address, and telephone number of the placement worker and placement agency.
(6) Educational records, if available, describing the child's present academic level, including their grade or performance level, and any previous school-related problems.
(7) Dental and medical history, if available, including immunization records; and physician's orders for any medically necessary diet as specified in Section 80076(a)(6).
(8) The child's court status, if applicable, including a copy of any custody orders and agreements with parent(s) or person(s) having legal custody.
(9) The placement agency's list of persons who should or should not be allowed to visit.
(A) Notwithstanding (b)(9), the facility's visitation policy must be in accordance with the child's personal rights as specified in 84072(d)(8).
(10) Any special dietary needs or practices.
(11) Medical, psychiatric and psychological reports that identify special needs of children diagnosed as mentally disordered or developmentally disabled.
(12) Medical and dental insurance coverage information, or information regarding the agency or person responsible for medical and dental costs.
(13) Consent forms, completed by the child's authorized representative(s), to permit the facility to authorize medical care.
(14) A copy of the standard appraisal form specified in Section 84068.1(b)(1)(C), if used.
(15) A copy of the current court order, or written authorization of the child's parent or guardian, for each psychotropic medication, as defined in Section 84001(p)(4).
(A) Written authorization of the child's parent or guardian may only be documented in lieu of a court order if the child is not a dependent or ward of the court, or it is documented in the child's record that the county placing agency has verified a court order is not required.
(B) This section shall not apply when the child's record contains documentation from the child's prescribing physician that the psychotropic medication has been provided in an emergency situation, as described in California Rules of Court, rule 5.640.
(16) A separate log for each psychotropic medication prescribed to the child documenting all the following:
(A) The name of the medication.
(B) The date of the prescription.
(C) The quantity of medication and number of refills initially prescribed.
(D) When applicable, any additional refills prescribed.
(E) The prescribed dosage and directions for use as specified in writing by the physician prescribing the medication, including any changes directed by the physician.
(F) The date and time of each dose taken by the child.
(G) Documentation of each refusal.
1. Documentation shall include the name of the medication refused, date and time of the refusal, the reason for the refusal, who was notified of the refusal, and any observed results of the refusal.
(H) Staff initials for each time a psychotropic medication is taken by a child, as an indication that they supervised the child self-administering their psychotropic medication.
1. Initials shall not be pre-filled on the log.
(17) The original documentation signed by a child and their authorized representative acknowledging receipt of information regarding a child's personal rights as specified in Section 84072(c).
(18) The names and contact information for the child's social worker(s), probation officer(s), attorney(s), service providers, foster youth advocates, Court Appointed Special Advocates (CASAs), and education rights holder if other than the parent or parents, and when applicable, representatives designated by the child's Indian tribe to participate in the juvenile court proceeding, information that the child is entitled to receive from the placing agency pursuant to section 16001.9(a)(11) of the Welfare and Institutions Code.
(c) If it is determined that the facility can provide the services necessary to meet the child's needs, the following additional information shall be maintained in the child's record:
(1) A copy of the child's original needs and services plan; verification, signed by the child and their authorized representative(s), that they were offered the opportunity to participate in plan development; and verification that the authorized representative(s) have approved the plan.
(2) Signed copies of the facility's policies and procedures regarding the child's removal and/or discharge; discipline; and complaints.
(3) Documentation that vaccinations have been obtained as specified in Section 84069.1, if immunization records are not available prior to placement.
(4) Records and documentation regarding any fines levied as specified in Sections 84026(c)(1) through (4).
(5) Copies of any modifications to the child's needs and services plan; verification, signed by the child and their authorized representative(s), that they were offered the opportunity to participate in any such modifications; and verification that the authorized representative(s) have approved such modifications.
(d) If it is determined that the child is to be removed or discharged from the facility, the following information shall be maintained in the child's record:
(1) Date the child's authorized representative(s) was notified of the necessity for the child's removal or discharge.
(2) The name, address, and relationship to the child of the person to whom the child was released.
(3) Reason for the child's removal or discharge.
(e) Consistent with Sections 80070(c) and 84072(d)(38), a licensee shall maintain the confidentiality of all medical and mental health records and information obtained from or regarding a child, including, but not limited to, HIV status, substance use disorder history and treatment, and sexual and reproductive health care.
(1) Client records shall remain available to the licensing agency to inspect, audit, and copy upon demand during normal business hours, consistent with Section 80070(d).
Credits
Note: Authority cited: Sections 1530 and 1530.91, Health and Safety Code. Reference: Sections 1501, 1507, 1507.6 and 1531, Health and Safety Code; and Sections 369.5, 739.5 and 16001.9, Welfare and Institutions Code.
History
1. Amendment of subsections (b)(1) and (c )(4) filed 7-26-91; operative 8-26-91 (Register 91, No. 51).
2. New subsections (b)(12)-(b)(13)(H)1. and amendment of Note filed 5-20-2020; operative 7-1-2020 (Register 2020, No. 21).
3. Amendment of section and Note filed 3-1-2024; operative 7-1-2024 (Register 2024, No. 9).
This database is current through 7/12/24 Register 2024, No. 28.
